More Information Available Now with EBT

From the Texas WIC Director— Mike Montgomery

This edition of the Texas WIC News focuses on the redemption data that Texas WIC is able to obtain from the electronic benefit transfer (EBT) card use. It is really exciting to be able to look at actual redemption of the WIC approved foods. Now we can not only see how much of a food category is being purchased; we can see exactly which product was chosen. With EBT information, we have more information available now than ever before in the history of WIC.

We can use the information to decide what education classes are needed to steer our participants toward healthier choices within the allowable foods. For example, we may decide to look at areas of the state that have a higher rate of families purchasing fat-free milk. From there we could identify which clinics they attended and work with those clinics to identify what attitudes or ideas are different in that area of the state.

We can examine the actual redemption of national and store brands on our allowable food list and determine if there are some brands that are not being purchased by our participants. This information will be helpful if we decide to limit the number of brands we approve.

We will be able to check the seasonal influences on the purchases of fruits and vegetables. Based on that information, clinics could promote the products that are in season and available right in their own area of the state. We are hoping that clinics can introduce our clients to new fruits and vegetables to add to their diets.

As mentioned in many of the articles in this edition, we are comparing data obtained by NATFAN and TEXFAN to what our actual redemption information shows. This will give us excellent information about the parent or guardian's perception of their purchasing habits.

Shopping for WIC foods has always been somewhat difficult for the new participant. We can continue to make it positive by watching what they purchase and listening to what they say. Endless possibilities exist for use of this redemption data to help the WIC participant and improve the services our program provides.

WIC Explores the Redemption Rates of Soy, Tofu, Tuna and Salmon

by Tonia Swartz, R.D., L.D.Clinical Nutrition Specialist

To accommodate more variety and choice for WIC participants, U.S. Department of Agriculture added soy milk, tofu and salmon as WIC food package options in October 2009. The response from Texas WIC participants to these new food package options has been interesting.

Pre-ImplementationIs soy milk or tofu even an item many participants include in their diet? In 2009 Texas A&M University, in conjunction with Texas WIC, conducted a survey among WIC participants called the TEXFAN Survey. Participants were asked a series of questions about their dietary habits prior to the implementation of the new food package rules. The following is a brief summary on the survey results for soy and tofu.

Soy Milk

Survey results for soy and tofu

How often do you drink soy milk? (6315 respondents)

Never or less than once per week

1 to 3 times per week

2 times per day

5624(88.9%)

235(3.7%)

111(1.8%)

When asked how often they drink soy milk, 88.9 percent of the respondents answered that they never drink soy milk or drink soy milk less than one time per week. The percentage of participants who drank soy milk one to three times per week was 3.7 percent; while those drinking soy milk at least two times per day were 1.8 percent. As for the type of milk participants are drinking, 1.5 percent indicated soy milk as their primary choice as opposed to 76.0 percent who chose white cow's milk.

Tofu

With tofu, 85.5 percent of participants surveyed indicated that they never eat tofu or eat tofu less than one time per month. Only 2.3 percent of the participants consume tofu two to three times per month and 2 percent consume tofu two times per week.

Post-Implementation So how would Texas WIC participants respond to the new food package options in regards to soy and tofu? Would those percentages change? Would there be a strong demand? A follow-up TEXFAN survey is completed but not yet tallied. In the meantime, we do have some preliminary numbers that can help the state gauge participant response.

In looking at issuance numbers from September 2010, a total of 3,381 soy milk/cheese or soy milk/tofu food package options were issued. Food package 476 (less than 2 years: Soy Milk/Cheese/Beans) was the most frequently issued soy package at 981 packages or 29 percent, followed by food package 463 (2 plus years: Soy Milk/Cheese) with 795 packages issued or 24 percent. Food package 464 (2 plus years: Formula/Soy Milk/Tofu) was the least issued at 0.6 percent. While these numbers do not distinguish between food packages issued out of participant preference or medical need, soy milk is generally issued more often for lactose intolerance or deficiency and/or milk allergy.

When you compare soy milk and tofu food packages by ethnicity, 60 percent of the soy and tofu package options were issued to Hispanics, 22 percent to whites and 13 percent to blacks, again with food package 476 being the most frequently issued package across all three ethnicities.

The state health regions issuing the most soy milk and tofu food package options include Region 6 (Houston and surrounding area) followed by Region 3 (Arlington and surrounding area). These numbers may in part be indicative of product availability. These regions are larger and more urban and therefore, may offer a wider variety, when compared to rural area stores.

When you compare soy milk/cheese food packages against soy milk/tofu packages, the soy milk/cheese food packages are issued up to approximately 2.5 times more than the soy milk/tofu food packages.

More information on participant dietary habits as they relate to the new food package options will become available with the post-NFR (new food rules) survey, in the meantime, as the numbers indicate, WIC participants are indeed buying soy milk and tofu. Vendors can use this information when deciding on product availability for their area, so hopefully the option will be available to more WIC participants.

We can continue to help our participants by encouraging their choices with positive reinforcement, providing up to date education information on food sensitivities and allergies, and on the health benefits of soy when part of a healthy diet.

Tuna and SalmonTuna and salmon were not included in the pre-NFR survey questions; however, the state does keep track of the redemption data.

Pre-NFR, exclusively breastfeeding (EBF) women received canned tuna as a part of their food package. With the implementation of the new food packages, canned salmon was added as an additional nutrient source and option to the exclusively breastfeeding mom.

As of September 2010, the number of EBF food packages that were issued totaled 19,157 and approximately 70 percent of those participants redeemed their tuna or salmon. The redemption numbers for tuna and salmon have remained relatively steady at approximately 92 percent tuna redeemed and 7 percent salmon redeemed.

As many nutritionists and registered dietitians can tell you, fish is an important nutrient source for the breastfeeding mom and her infant. Fatty fish like tuna and salmon are a good source of omega-3 fatty acids, an essential fatty acid also referred to as docosahexaenoic acid (DHA). DHA is important in an infant's brain growth and functional development, and infants can only obtain DHA through diet, e.g. mom's breastmilk. The Food and Drug Administration recommends pregnant or breastfeeding women consume up to 12 ounces per week of a variety of low mercury containing fish, such as canned light tuna or salmon. Salmon is also a dietary source for vitamin D, another nutrient important in an infant's skeletal development.

It is important that we continue to encourage healthy food choices for our participants, further emphasizing to our breastfeeding mom's the health benefits of fish consumption and the positive effects on their infants growth and development.

Whole Grain Redemption Trends

by Paula Kanter, R.D.Clinical Nutrition Specialist

Awareness of the benefits of whole grains has risen in recent years due in part to U.S. Department of Agriculture's 2005 Dietary Guidelines, which recommend a 3-oz-equivalent of whole grains per day to help reduce the risk of coronary heart disease, maintain a healthy weight, and lower risk for other chronic diseases.

In 2010, wheat bread sales surpassed white bread in dollar sales for the first time ever according to Nielsen data. The best performing breads are promoting "whole grain" and "natural," sometimes asking consumers to pay more for those loaves.

The Texas Food and Nutrition (TEXFAN) Questionnaire results show the frequency of consumption of whole-grain products prior to implementing the new food rules.

Whole Grains

Whole-Grain Products

Responses

Percent

Whole-wheat tortillas

Never

66%

Eats whole-grain product

34%

Corn Tortillas

Never

26.2%

Eats whole-grain product

73.8%

Whole-wheat/whole-grain bread

Never

23.5%

Eats whole-grain product

76.5%

Brown Rice

Never

64.3%

Eats whole-grain product

35.7%

Oatmeal

Never

37.1%

Eats whole-grain product

62.9%

Note: "Eats whole-grain product" comprises all responses other than "Never or less than once per week."

Agrilife Research & Extension Texas A & M Systems/Institute for Obesity Research and Program Evaluation

According to the survey, participants' knowledge and their ability to identify whole-wheat and whole-grain bread showed that 75 percent claimed they were able to use labels and were sure they were able to select a whole-wheat or whole-grain bread.

When we look at EBT redemption data from October 2009 through July 2010, about half the purchases for whole grains are for whole-wheat bread.

When we look at EBT redemption rates for all whole grains, only 52 percent of the issuances for whole grain were redeemed. This was during the initial implementation of the new food rules. During that time, stores were in the process of adjusting their stock of approved brands to meet the demand from WIC participants. Since this was a new food item for WIC, vendors had no purchasing history and had to work with projected numbers.

Grain redemption

Grains

Oct 2009

July 2010

Item # Description

Redeemed

% of Total

Redeemed

% of Total

Whole-Wheat Bread 16 oz

24,398

45.55%

406,748

52.52%

Corn Tortillas 16 oz

14,125

26.37%

229,554

29.64%

Wheat Tortillas 16 oz

4,642

8.67%

49,864

6.44%

Brown Rice 16 oz

5,447

10.17%

30,390

3.92%

Oatmeal 16 oz

4,947

9.24%

57,915

7.48%

In September 2010, one year after implementation of the new food packages, we find that redemption has increased to 64 percent, which is an improvement but not optimal when the goal is to increase whole grains in the diets of our WIC participants.

Several factors may impact the low redemption of whole grains. Factors that WIC participants mentioned in focus groups conducted by SUMA/Orchard in Summer 2010 included the following challenges:-Participants cannot find the right WIC-approved items at the store.-Participants can find the correct brand, but not the right size.-Shelves lack WIC labeling.-Bread can be hard or impossible to find in the right size.-Stores are out of stock.Results from the TEXFAN Questionnaire unsurprisingly show that our participants eat more white rice than brown rice and more white-flour tortillas than whole-wheat tortillas. WIC staff can be instrumental in helping WIC participants try healthier whole-grain options by providing recipes. In the SUMA focus groups, one participant shared that she was surprised at how good whole-wheat tortillas tasted and she would not have tried them had they not been provided by WIC.

Fruit and Vegetable Redemption Rates Show Significant Increases

Since the new food rules went into effect in October 2009 redemption rates for the cash value fruits and vegetables have increased. In fact the rates' increase from 65 percent in October 2009 to 78 percent a year later in September 2010 is quite significant. However, also of significance is the fact that 22 percent of cash benefits are not being redeemed.

The challenge for WIC staff is to help participants understand how to get the most out of their fruit and vegetable benefits through purchasing choices that will provide them with a greater nutritional value.

Participants' Perception of Fruit and Vegetable Consumption In the fall of 2009, prior to the implementation of the new food rules, over 80,000 WIC participants were surveyed nationwide. The National Food and Nutrition (NATFAN) survey is a national multi-year study designed to identify changes in WIC participant food and nutrition behavior before and after the WIC food package. The results of the survey captured a snapshot of the consumption and food frequency patterns of WIC participants. A similar survey of over 6,500 WIC participants was also conducted among 73 local agencies in Texas during the months of November 2008 and April 2009 as part of the TEXFAN survey. The results of that survey indicated consumption, purchasing and feeding patterns of WIC participants in Texas prior to the new WIC food package rollout. Several consistencies in fruit and vegetable intake were noted in both surveys. That is, Texas WIC participants tend to eat the same fruits and vegetables as other WIC participants nationwide.

When looking at women participants in Texas, the top five fruits consumed at the time of the survey were almost identical to consumption nationwide. The same is true for vegetable consumption.

Top Fruits Consumed

Top 5 Fruits Consumed by Women WIC Participants

Nationwide

Texas

Apples

Bananas

Bananas

Apples

Grapes

Grapes

Oranges

Oranges

Strawberries

Strawberries

Top 5 Vegetables Consumed

Top 5 Vegetables Consumed by Women WIC Participants

Nationwide

Texas

Corn

Corn

Lettuce (all varieties)

Lettuce (all varieties)

Carrots

Carrots

Broccoli

Tomatoes

Tomatoes

Broccoli

Comparing data, Texas children consumed more watermelon than children nationwide. As far as vegetable consumption, both groups of children preferred to eat green beans over lettuce. Lettuce was more popular among women.

Fruits consumed by children

Top 5 Fruits Consumed by Children WIC Participants

Nationwide

Texas

Bananas

Bananas

Apples

Apples

Oranges

Grapes

Grapes

Oranges

Strawberries

Watermelon

Top 5 Vegetables consumed by Children

Top 5 Vegetables Consumed by Children WIC Participants

Nationwide

Texas

Carrots

Carrots

Corn

Corn

Broccoli

Broccoli

Green Beans

Tomatoes

Tomatoes

Green Beans

EBT Reports of Participants' Purchases of Fruits and VegetablesWhile the NATFAN and TEXFAN captures participant's self-reported consumption, Texas WIC has the ability to view actual purchasing through EBT reports. The EBT reports tell us those fruits and vegetables purchased with the $6 and $10 monthly cash value awarded to WIC's children and women. The EBT report only shows those items which are WIC approved and therefore does not show participants' purchases of white potatoes, canned vegetables, dried fruits and other non WIC-approved foods.

Also, the report shows the dollars spent to purchase fruits and vegetables and not the amounts in number, size, or weight. A dollar spent on strawberries in July, when strawberries are in season, buys a lot more strawberries than a dollar spent on strawberries in January.

The following tables show the top five fruits purchased and the top five vegetables purchased for the month of September 2010. The tables list the fruits and vegetables and their respective percentage of cash value dollars spent.

The actual purchasing of fruits by Texas WIC participants is very similar to that of WIC participants nationwide. Had peaches, nectarines, plums, etc. not been combined in the Fruit Vegetable Summary, oranges would have made the top five fruits purchased list with 4.7 percent of the cash value dollars spent. Vegetable consumption, on the other hand, was quite different with avocados and onions both making the top five vegetables purchased list.

Purchased fruit

Top 5 Fruits Purchased

Fruits Purchased

Percentage of Cash Value Dollars Spent

1. Bananas

11.5%

2. Grapes

9.5%

3. Apples

9.1%

4. PeachesNectarinesPlumsApricotsCherries

6.8%

5. StrawberriesBlackberriesRaspberries

6.0%

Vegetables purchase

Top 5 Vegetables Purchased

Vegetables Purchased

Percentage of Cash Value Dollars Spent

1. Tomatoes

8.4%

2. Avocados

4.6%

3. Peppers

3.9%

4. Onions/Leeks

3.8%

5. Lettuce

3.6%

SUMA WIC Redemption Study FindingsSUMA/Orchard Social Marketing, Inc. conducted a series of focus groups and one-on-one interviews with Texas WIC mothers to determine why they are not redeeming all of their food benefits each month.

The SUMA studies with WIC participant focus groups revealed that some participants were not aware of various allowed produce, such as organic and bagged single-item fresh produce, even though these items are listed as allowed in the Fruit and Vegetable Shopping Guide. In addition, some WIC participants stated that they did not find the Cost Chart in the Fruit and Vegetable Shopping Guide useful. These insights would indicate that WIC staff may need to further educate participants using these WIC materials. Hands-on counseling and group classes that cover purchasing produce may be beneficial in improving participants' knowledge of allowed and not-allowed produce and use of the Cost Chart.

WIC participants in the focus groups also reported discrepancies in the weight readings of scales in the produce department and at the cash register. They often experienced rejection of their fruit and vegetable purchases at the cash register due to the dollar amount exceeding their cash value benefit. Such occurrences may lead to embarrassment and consequently, under-redemption of benefits.

ConclusionMany factors influence WIC fruit and vegetable redemption rates. The SUMA studies illustrate that education at WIC clinics, participants' shopping experiences, and educational materials such as the Fruit and Vegetable Shopping Guide are all factors that impact produce redemption rates. Many WIC respondents indicated they would like to have additional hands-on learning activities to better understand why certain fruits and vegetables are allowed and others are not. Although the grocery store experience may be confusing to participants at times, it should be noted that WIC participants reported that they are pleased to be able to purchase fruits and vegetables even though some benefits remain unredeemed.

Improving Participants' Nutritional Bang for their Bucks

In addition to teaching WIC participants to use and understand the Fruit and Vegetable Shopping Guide and the Cost Chart, other recommendations WIC staff can make in group classes and individual counseling sessions that would help participants receive greater value for their cash benefits include buying: 1. Fruits and vegetables in season.2. Locally grown fruits and vegetables and shopping farmers markets.3. More nutritionally dense varieties of produce when available.4. A variety of fruits and vegetables.

Let's briefly look at each of these points.

-When fruits and vegetables are in season and they are at their nutritional height, the cost generally goes down. This is a good time for participants to buy; they get more for less! When a produce is not in season, frozen alternatives should be considered. Frozen strawberries may be an acceptable substitute in some recipes and they are significantly cheaper than fresh strawberries in winter and spring. For a list of fruits and vegetables in season, check out the Texas Department of Agriculture site, www.picktexas/product/produce_avail_main.htm. For the month of May, blueberries, cantaloupe, greens, and sweet potatoes are in season along with other fruits and vegetables. -Locally grown fruits and vegetables are supposedly a better buy since they should be fresher and more nutrient dense than fruits and vegetables that were harvested days and weeks earlier and shipped across the country. Also, since transport to farmers markets and to local grocery stores is minimal, shipping costs should not be incurred, and thus not added to the price of the produce.-When more nutritionally dense varieties of similar produce are available, encourage participants to buy those varieties. Consider lettuce as an example. Romaine lettuce is a better nutritional choice than iceberg lettuce and it is often priced equivalently. -Variety is very important. Different fruits and vegetables offer different nutrients, and no one food offers all nutrients. EBT reports show a vast variety of fruits and vegetables purchased by Texas WIC particpants.

WIC Wellness Works: Pre-Diabetes - Take Charge Now!

There is a good chance you know someone who has diabetes. Perhaps your parents, an aunt or uncle, grandparents, sibling, or even a neighbor has been diagnosed with diabetes. Right now 1 in 10 Americans has diabetes, but by 2050 that number could soar to 1 in 3 Americans who are affected by the disease. This does not have to be your future if you take charge now.

Type 2 diabetes, the most common type, is a disorder that affects the way the body uses digested food for growth and energy. Most people with type 2 diabetes have an insulin resistance condition in which muscle, liver, and fat cells do not use insulin properly and/or their body cannot produce enough insulin. This insulin resistance condition disrupts the body's ability to convert food into energy, and the result can be deadly. Adults with diabetes have increased heart disease death rates and stroke death rates, approximately two to four times higher than someone who does not have diabetes.

Do you have pre-diabetes? Find out now!You can take charge now by looking for the early signs of diabetes. According to the U.S. Department of Health and Human Services, 1 in 4 Americans have pre-diabetes which means they have blood glucose levels higher than normal but not high enough for a diabetes diagnosis. Pre-diabetes indicates that someone is likely to develop type 2 diabetes within 10 years unless they take steps to prevent or delay diabetes.

What are the risk factors for pre-diabetes?Overweight -Being overweight (20% over ideal weight) is a primary risk factor. The more fatty tissue you have -especially around your abdomen -the more resistant your cells become to insulin.Inactivity -The less active you are, the greater the risk. Physical activity helps control your weight, uses up glucose as energy, and makes your cells more sensitive to insulin.Age -The risk of pre-diabetes increases as you age, especially after 45. This may be because people tend to exercise less, lose muscle mass, and gain weight as they age. Family History -Pre-diabetes risk increases if a family member has diabetes. Your risk increases if a parent or sibling has type 2 diabetes.Race -African Americans, Hispanics, American Indians, Asian-American, and Pacific Islanders are at greater risk. It is unclear why certain races are more likely to develop pre-diabetes than others.Gestational diabetes -Your risk of later developing diabetes increases. Diabetes related to pregnancy or giving birth to a baby who weighed more than nine pounds increases the risk of diabetes.

Other conditions that affect your risk of pre-diabetes include a low HDL (high-density lipoprotein) level, elevated triglyceride level, as well as high blood pressure.

GOOD NEWS-If you have pre-diabetes, you can and should do something about it. According to the American Diabetes Association, the Diabetes Prevention Program (DPP) study showed that people with pre-diabetes can prevent or delay the development of type 2 diabetes by up to 58 percent through changes in their lifestyle that include modest weight loss and regular exercise.

This study conclusively showed that some medications may delay the development of diabetes but diet and exercise worked better. Exercise helps control type 2 diabetes by improving your body's use of insulin and by burning excess body fat and helping to decrease and control weight.

Formula for SuccessJust 30 minutes a day of moderate physical activity, coupled with a 5 to 10 percent reduction in body weight, will move you forward in this fight and possibly enable you to return your blood glucose levels to the normal range. The key to success is to schedule exercise into your daily routine. Consider what type of exercise you like, select a convenient time of day and determine a realistic length of time for each exercise session. Grab your calendar and pencil it in. Let friends, family, and co-workers know about your commitment and seek their support. A weekday schedule might look like this:

Weekday Schedule

Day

What

When

Duration

M-F

Walk

lunch break

20 minutes

M-F

Walk

afternoon break

10 minutes

Don't forget Saturday and Sunday when you might have more flexibility in your schedule. Form the exercise habit as soon as you can.

Next Steps for Taking ChargeIf you don't know if you are at risk for pre-diabetes, take action now. Visit your physician and have your blood glucose levels tested. Begin an exercise program, monitor the number of calories you consume, and start controlling your weight. It is much more effective to make lifestyle changes now than to wait until you are diagnosed with diabetes. At that point, your body can no longer effectively process insulin and managing your food intake and activity levels becomes more serious and might be life threatening. Take charge now so that your future might be "diabetes-free."

LA 73 employees had so much fun accumulating almost 21,000 exercise minutes over six weeks when competing in the WIC Wellness Works' initiative, Walk the World with WIC, that they started another challenge to keep everyone active.

"The measuring wheel that we won in the Walk the World with WIC challenge has been very useful. We measured out indoor and outdoor routes and have marked off the distances so everyone knows how far they are walking," said Teresa, a nutritionist for 10 years with WIC. "Now we have a new competition underway." LA 73 has three clinics and approximately 37 staff participating in the wellness program.

"Everyone wanted to keep walking so we decided that we would create a new competition to keep us motivated and we wanted to keep it fun," she added. This time they are counting calories. "Our registered dietitian created a graph that shows how many calories you burn per hour doing a number of different activities. It is based on weight and calories burned per hour," said Teresa. "All of the employees keep track of their daily calories burned. They divide their time into one hour if they are not active for a whole hour."

Teresa said employees are trying to eliminate 500 calories a day for gradual weight loss by tracking their calories burned each day. In doing this, they are able to see how much physical activity it takes to burn 3,500 calories or one pound. Daily totals are recorded and then each weekly total is posted on the wall chart for everyone to see.

"As we are a very competitive group, the wall chart works great," said Teresa. "Everyone wants bragging rights!"

In addition to the wall chart, Teresa has created a bulletin board with pictures of many different snacks and the number of calories in each snack. "This has been a real eye opener for many of the staff. Most people had no idea it took so much physical activity to burn off the calories in the snacks we were eating. Everyone has been very serious about this," Teresa shared. She is also working to get pedometers for everyone so that they can keep track of their steps as well.

Teresa says LA 73 would like to keep this challenge going all year but knows she will have to change things to keep people interested. "I think if we can keep some type of challenge involved, we'll be successful," says Teresa. "This group will do almost anything to be crowned the winner!" LA 73 has created a fun, team-building initiative to motivate staff to increase their physical activity as well as help them to pay attention to the calories they are consuming. Promoting the physical activity challenge helps to keep it fresh and ongoing and provides an environmental aspect to the initiative. Physical activity becomes part of the local agency "norm" and the bulletin board and tracking chart act as cues to employees to continue walking and to monitor what they eat. This is a great way to make physical activity and healthy eating part of everyone's daily life. Anyone want to challenge LA 73 to a wellness competition? There are pretty good odds that they will take you on.

DirectionsCut papaya and guava into thin slices. Julienne (cut into thin slices) the Asian pear. Put the spring mix salad in a large bowl. Toss with dressing. Mound on a platter. Place fruit slices on top and serve.

local agency spotlight: Hidalgo County WIC Has New WIC Mobile Unit and Transit Vehicle

Hidalgo County, Local Agency 12, has a new WIC mobile unit. After months of planning and preparation -from the bidding process to the floor plan design -the new WIC mobile unit finally became a reality July 2010. The new mobile unit replaces one that had been in use for five years by the LA.

The mobile unit was wrap-designed with the new WIC food package on one side. The other side displays the World Breastfeeding Month babies and the "Every ounce counts" logo. The WIC logo and the LA toll-free phone number are also displayed on each side of the mobile unit.

The mobile unit has five full-time staff: LVN, WCS, clinic aide, clerk, and a breastfeeding peer counselor. The mobile unit travels to different colonias in both Hidalgo and Starr Counties, serving over 1,940 participants monthly.

Hidalgo County WIC also got a new 2010 Ford Transit vehicle. The vehicle, which is wrap-designed with the WIC logo, is used for delivery of supplies to the clinics and to transport staff to sites.

CONTRACT FORMULA vs NON-CONTRACT FORMULA

by Maricela Montoya, M.S., R.D.Clinical Nutrition Specialist

Standard infant formulas are either made with cow's milk protein or soy protein and are generally used for healthy full-term non-breastfeeding infants. Texas WIC currently has a contract with Abbott, the makers of Similac formulas, to furnish all WIC clients who need formula. The current contract formulas offered are Similac Advance, Similac Sensitive, Similac Sensitive Isomil Soy and Similac Sensitive for Spit-Up. Also available through the WIC program are low-lactose and lactose-free milk and soy-based products.

Use of Contract FormulaOf all participants on formula over 91 percent are on either milk or soy-based contract formula. Of the contract formulas issued, 92 percent were milk-based and 8 percent were soy-based.

Non-Contract FormulaIn some cases, infants may not be able to tolerate any of the contract formulas that Texas WIC provides and the Health Care Provider (HCP) may request a standard non-contract formula. All non-contract formulas require a prescription for a valid medical condition. All infants placed on non-contract formula are challenged routinely with the contract formula so that they may be switched when appropriate.

Texas WIC may provide the non-standard contract formula for a maximum of three months and then a comparable contract formula must be tried again. The retrial of the contract formula will occur unless the physician has stated the infant is unable to retry the contract formula due to severe or exceptional medical conditions.

As shown by table 1, for the months of April through September 2010, the percentage of participants on non-contract milk-based formula is 1.67 percent and 0.14 percent on a soy-based non-contract formula.

Use of contract and non-contract formulas

Total % of Contract, Non-Contract, and Exempt Formulas Issued between April through September 2010

April

May

June

July

August

September

Total % on Contract Milk Based Formula

84.23

84.18

84.28

84.40

84.44

84.37

Total % on Contract Soy Based Formula

7.64

7.55

7.46

7.30

7.14

7.06

Total % on Milk & Soy Contract formulas

91.87

91.73

91.75

91.70

91.58

91.42

Total % Non-Contract Milk Based Formula

1.66

1.64

1.67

1.67

1.68

1.72

Total % Non-Contract Soy Based Formula

0.13

0.12

0.13

0.14

0.14

0.15

Total % Exempt Formula

6.34

6.51

6.45

6.50

6.60

6.71

*All values are represented as percentages

Exempt FormulaAn exempt formula can be defined as a therapeutic formula intended and labeled for use by individuals with specific medical or dietary conditions. All exempt formulas require a prescription from the physician and also need to be approved by the appropriate WIC certifying authority prior to issuance. The WIC formula approval process is a safety net to ensure the formula is being provided for the medical conditions indicated by the manufacturer. Due to the increased changes to formulas and formulas available on the market, there is an increased likelihood of accidental errors in reasons for prescribing. Sometimes a physician will request a formula that is outside the recommended usage, and upon determining that the intent was to do exactly that, WIC will approve. This process provides the best practice to WIC participants and their physicians.

Exempt formulas are not covered by rebate contract and do not require a retrial of contract formula. Texas WIC provides approximate 6.5 percent of all formula issued to participants having special needs.

Infant Cereal Redemption Trends

by Sandra Brown, M.S., R.D.Food/Formula Specialist

Infant cereal is not a new food for WIC. It was provided in the original WIC food packages by federal regulation to improve the iron status of infants. The minimum iron requirement for infant cereal is 45 mg per 100 gm dry cereal. WIC regulations do not allow infant cereal to contain infant formula, milk, fruit or any other non-cereal ingredients. This article will explore the issuance and redemption trends of infant cereal use before and after the implementation of the new WIC food packages in October 2009.

Infant Cereal Rebate ContractTexas WIC is one of a handful of states that has a contract with a single infant cereal manufacturer and therefore only provides one brand. The infant cereal rebate contract is similar to the one Texas WIC has with infant formula. The manufacturer that holds the contract pays the Texas WIC program a certain amount for each unit of infant cereal (or formula) sold to a WIC participant. The current infant cereal contract is with Gerber and began October 1, 2009. It will expire September 30, 2012 with the possibility of two one-year extensions. In fiscal year 2010, the Texas WIC program received over $1.3 million in infant cereal rebate payments that will allow us to serve additional WIC participants.

Over time, the manufacturers of infant cereal have made a number of changes to their product. Packaging has changed, and new varieties have been introduced along with added ingredients such as docosahexaenoic acid (DHA). To simplify shopping for participants, only infant cereals in boxes are allowed to be purchased with Texas WIC benefits.

Before October 2009Prior to October 2009 and the new WIC food packages, the infant cereal varieties included rice, oatmeal, mixed grain and barley. The average redemption of infant cereal from October 2008 through June 2009 was a relatively low 59 percent. Participants received infant cereal beginning at 4 months of age. At 6 months, two - 46 oz cans of juice (or two - 11.5 or 12 oz frozen) were added to the infant package. Formula quantities, if provided, were the same each month throughout the infant's first year of life.

After October 1, 2009Beginning in October 2009, several factors changed at the same time. The issuance of infant cereals is now postponed until infants reach 6 months of age. Juice has been eliminated and replaced by infant fruits and vegetables. Formula quantities change at various times during the first 12 months of life. From birth through 3 months of age, a fully formula fed infant receives about 26 reconstituted ounces daily. Now that infant cereal has been postponed, formula amounts increase at 4 and 5 months of age to about 29 ounces daily. At 6 months, the formula quantity decreases to about 20 ounces when supplementary cereal, infant fruits and vegetables are offered.

The varieties of infant cereals offered have changed as well. Texas WIC continues to provide rice, mixed grain and oatmeal, but has replaced barley with whole wheat.

Exclusively breastfed infants receive twice the amounts of infant fruits and vegetables along with infant meat.

Redemption TrendsAugust 2009 was the first month Texas WIC provided all participant foods using electronic benefits transfer (EBT) cards. Prior to that time when benefits were provided by voucher, redemption rates averaged 71 percent. At that time, it was not possible to know how many or what kind of cereal was actually purchased. It was assumed that if a voucher was redeemed, the full quantity had been purchased. With EBT, it is possible to know not only how many boxes were purchased, but what varieties. Table 1 shows the varieties and percentages purchased of each for the months August 2009 and August 2010.

As you can see, rice cereal is the most frequently purchased variety, followed by oatmeal and mixed grain cereal. Barley was offered during the previous contract but was replaced by whole wheat during the current contract. So far, whole wheat at 8.65 percent appears to be more popular than barley. Rice cereal amounts have decreased but seem to have been replaced by whole wheat purchases. Oatmeal and mixed grain cereal purchase amounts have remained about the same. Overall, since infant cereal is issued for fewer months, less is purchased. In addition, the percent redeemed after October 2010 has dropped to 52 percent.

Below is table 2 showing infant cereal issuance and redemption by age for the month September 2010.We have always suspected that redemption percentages would drop as infants move through the first year. We now have some preliminary redemption data that seems to support this assumption. Quantity purchased and percentage redeemed seems to peak between 6 and 7 months of age at about 72 percent. Texas WIC provides infant cereal to infants who reach 6 months of age on or after the first day of the calendar month. Most of our infants are almost 7 months of age when they first receive infant cereal from WIC. The lowest redemption percentage appears to be around 11 months of age (at about 48 percent). Unfortunately, participant surveys haven't identified why infant cereals are not redeemed at higher levels. It may be due to postponing infant cereal issuance for two months. Many families have already started offering infant cereal prior to 6 months of age. Anecdotal evidence suggests that infants outgrow the texture of infant cereals before the end of the first year. They may be ready to move on to hot cereals or oatmeal that older siblings or parents are consuming. Ready to eat cereals that help infants practice their newly developed pincer grasp may also be more appealing.

Infant Cereal Redemption by Age

Table 2: Infant Cereal Issuance and Redemption by Age for September 2010

Age in Months

Participants issued infant cereal

Participants redeeming infant cereal

Percentage Redemption

6

1,028

749

72.86%

7

17,840

12,629

70.79%

8

19,533

12,229

62.61%

9

20,855

12,293

58.95%

10

18,665

10,481

56.15%

11

19,713

10,166

51.57%

12

17,484

8,337

47.68%

In summary, infant cereal is often one of the first supplementary foods offered. Rice cereal appears to be the most frequently purchased variety. Redemption of the infant cereal category seems to peak at 6 to 7 months of age and slowly decrease over the next five months. More research is planned in the future as we continue to explore the redemption of all WIC foods and encourage their consumption.

How Baby Foods Impact the WIC Redemption Rates

by Roxanne Robison, R.D.Children with Special Health Care Needs

and Cathy Plyler, R.D.Children With Special Health Care Needs

The implementation of new food rules resulted in big changes to the infant food packages. The new food packages for infants delayed the introduction of cereal and eliminated fruit juices. A significant change was the addition of baby foods including fruits, vegetables and meats. Formula fed infants over 6 months of age receive 32 four ounce containers of baby food fruits and vegetables. Exclusively breast fed infants receive 64 four ounce containers of baby food fruits and vegetables and 31 four ounce containers of infant meats. This article will review the rationale for adding baby foods to the WIC food packages and recent data on the redemption of baby foods. The reader will find suggestions for promoting the change to infant food packages to participants. After all, the nutritional benefits of the new food packages are only beneficial if the participant consumes them.

Why Were Food Packages for Infants Changed?The Committee on Nutrition of the Institute of Medicine (IOM) revised the WIC food packages in order to increase some nutrients lacking in the diets of some WIC participants and to decrease some nutrients that were found to be excessive in other groups. Specific changes in the WIC food packages were in response to help make WIC participants' diets more consistent with the Dietary Guidelines for Americans 2005.

Baby Food Fruits and VegetablesThe addition of baby food fruits and vegetables serve to introduce infants to new flavors and textures at a time when babies are developmentally ready (around 6 months of age). Fruits and vegetables replaced the juice that was previously offered to infants and lowers the calorie intake, as the amount of formula was reduced when baby foods are provided. Baby foods are only available to participants in four ounce jars due to food safety issues. The jar can be consumed in a single sitting or at least within the safe storage period for opened jars of refrigerated foods.

Baby Food Meats for the Breast-fed InfantThe IOM identified iron and zinc as nutrients that were inadequate in the diets of exclusively breastfed infants 6 months or older. Chemical analysis of breastmilk indicates that at 6 to 11 months postpartum, the iron and zinc content of breastmilk alone does not meet the nutritional needs of the older infant. Complementary foods become very important for the fully breast-fed infant, as baby food meats help to provide these nutrients in the infant's diet.

What Do We Know About Baby Food Redemption in Texas?The most frequently purchased baby food meat is chicken with about 31 percent of all purchases. Applesauce and bananas are at the top of all baby food fruits and vegetables purchased with each sharing about 19 percent of total sales. Carrots and sweet potatoes are the most frequent vegetables redeemed with approximately 10 percent each of the total fruits and vegetable baby food purchased.

When new foods were implemented in October redemption rates for baby food meats were at 60 percent and had decreased over time to 49 percent after the first year. Redemption rates for baby food fruits and vegetables are currently at about 61 percent with an increase over time from 53 percent at new food rules implementation.

Redemption rates also appear to change as the infant gets older. At age six months, less baby foods are redeemed, with the highest redemption rates peaking at about nine months of age. As the infant gets older the amount of baby foods redeemed decreases.

Why Are Total Benefits Not Being Redeemed?Only about 60 percent of fruits and vegetables are redeemed according to redemption data. Why are full benefits not being utilized? -Are the food packages providing too much food? -Is there not enough variety in foods provided? -Are older infants no longer interested in stage 2 textures?

The 2008 Feeding Infants and Toddlers Study (FITS)-Dietary Patterns of WIC Participants indicated that moms reported giving fresh and canned fruits and vegetables as well as baby foods. Redemption rates may correlate with moms continuing this practice.

The variety of baby foods that WIC provides is limited to single ingredient items. Recent market changes indicate a large variety of combinations of different fruits and vegetables may be more appealing than single ingredient items as the infant gets older. This could affect redemption rates as moms may opt to purchase other combinations of baby foods that WIC does not provide.

As the infant gets older they begin to consume more table foods, and therefore baby food redemption is decreased. Baby foods can still be incorporated in a variety of ways in the older infant's diet.

Single ingredient meats are often considerably less appealing than mixed meat and vegetable dinners. Most moms do not realize that meat is usually the least ingredient in mixed dinners and will provide less protein than the single meat variety.

What can we do to empower mom to utilize her WIC baby food benefits to the fullest?

Talking Points During VENA Counseling or ClassesEach time you visit with new moms, you have the opportunity to provide information or answer concerns regarding infant feeding. This will help impact the purchasing habits and utilization of the infant food package, including baby foods. For example:

When mom says...He doesn't like the meats. Either he doesn't like the texture or it tastes really strong.Suggestion: Try mixing small amounts of meat with a fruit he likes and then gradually increase the amount of meat over time. Adults do this all the time, e.g., ham and cherries, pork chops and applesauce, turkey and cranberries, etc.

Why can't my baby get the fruit and meat dinners instead?

Response: "Dinners" contain only a small amount of protein and other nutrients compared to pure meats. For example, a 4- ounce jar of Gerber Chicken and Apples contains 70 calories, 3 grams of protein and 2% and 10% of the daily value for iron and zinc, respectively. One jar of Gerber Chicken contains 100 calories, 8 grams of protein and twice as much iron and one third more zinc than the dinner contains. These are the nutrients that breastfed babies need more of at this age.

When mom says...Now that my baby is 9 months, he has outgrown the 2nd stage fruits and vegetables. Why can't he get the 3rd stage fruits and vegetables?

Response: Third stage baby food fruits and vegetables are similar in texture to the 2nd stage foods. They just come in a larger jar. The 2nd stage fruits and vegetables are given for safety reasons. The baby is meant to consume the entire jar in one feeding so that it will not spoil. If your baby is ready for a more difficult texture, try mixing in dry cereal to make it thicker and more challenging. The vitamin C in the fruits and vegetables also helps your baby absorb more of the iron that is in the cereal.

You can also try using the pureed foods provided in other foods with higher textures such as pureed meats on crackers. A mom of an older infant can also incorporate baby foods in other recipes like quick breads or casseroles. There are many recipes, and cookbooks that utilized baby foods in recipes, that can be given to the older infant.

Next year we will revisit redemption data on baby foods and hopefully with your efforts report increased utilization of the infant food package and improvement in infant's diets as well.

Training with the new CCNE DVD: It is worth the watch!

by Matt Isbell, Ph.D.The University of Texas at Austin Nutrition Education Group

This spring, all local agencies should receive a new client centered nutrition education (CCNE) staff training DVD titled The Real WIC World: Applying CCNE in the Clinic. The DVD was filmed with real staff and clients in real clinics, and includes examples from CCNE classes and testimonials. The DVD also contains a short booklet of discussion questions for each module to facilitate its use in staff training. Overall, the DVD is intended to complement the CCNE Toolkit and bring CCNE concepts to life. This article gives a brief taste of what to expect in each module, explores additional ways to use each module, and recommends some training ideas to get staff involved.

DVD Module One: Introduction to the Client-Centered Approach (8 minutes)"(Conducting a CCNE class) is almost like sitting at your kitchen table." -Local agency staff member on teaching CCNE classes

This module provides an overview of CCNE to help tackle the "why" questions: Why should we do this? Why is CCNE important? Why is client-centered so cool? It explores benefits of CCNE for clients and staff. Ways you can use Module One at your agency:-Watch the segments on client and staff benefits and ask staff to identify other benefits that are more specific to your agency. -Encourage staff to share specific stories about benefits they have experienced.

DVD Module Two: Foundations of Nutrition Education (13 minutes)"You don't realize (how you should change) until you say it, then you think, oh maybe I should really change something." -WIC participant after attending a CCNE class

This module explores several concepts in nutrition education and shows us what they look like in practice. Close the textbook and watch how theory is applied.

Ways you can use Module Two at your agency:-For each concept explored in the DVD (moving beyond knowledge, self-efficacy, social support), words flash on the screen. Ask staff to choose a word that hits home. Discuss how you can promote that concept in interactions with clients.-Visual aids are important to learning. Ask your staff to create a visual aid for a current class your agency is teaching (or about to teach). Bonus: If you have a bunch of great ideas, try one or two now and save the other ideas for later. This will keep classes feeling fresh.

DVD Module Three: Positive Learning Environment (41 minutes)"Sometimes you want to fill in that gap, but if you wait just a second longer somebody else will do it for you." -Local agency staff member on becoming comfortable with silence when facilitating CCNE classes

This module shares techniques on setting up a positive learning environment and handling common classroom challenges.

Ways you can use Module Three at your agency:-Observe the different classrooms shown during this module. Discuss with staff which classroom environments would work best for your clinics.-During the DVD's discussion on encouraging participation, one person stated that she had several key phrases to keep the conversation rolling. Have your staff come up with other phrases. Make a list of them and create a handout that you keep with your class materials.-The DVD shows a class where no one is talking. Ask staff to guess how long that silence lasted (Hint â€” it was less than 30 seconds). In staff trainings, practice the 30 second rule: Wait 30 full seconds before answering a question you asked. It almost always gives clients enough time to think about the question and build the courage to answer. -In the scene where misinformation is given, stop the DVD and ask staff members to explain how they would handle this situation.-Tip: Watch this module over the course of a couple of staff meetings. There are a lot of great learning points; you don't have to address them all at once.

CCNE classes can take a variety of forms. This module offers ideas for how to make client-centered classes happen at your agency.

Ways you can use Module Four at your agency:-Working in small teams, have staff pick one of the class types and create an outline of a new class using that format. The CCNE template and other materials in the CCNE toolkit can serve as supplemental resources. -Try making a CCNE contest among clinics to see what ideas staff have for making their classrooms more client centered.

This module provides excellent tips on ways to train and encourage staff to become more client-centered. With practice, staff will become more comfortable teaching CCNE classes.

Ways you can use Module Five at your agency:-Give staff some responsibility in the training process. Have your staff brainstorm the best ways to present a new CCNE class -Find your champions. Who are the staff members who can best promote the goals of CCNE?

And that is not all! The CCNE DVD is also packed with other useful footage and training material. Once you have trained on these five modules, show some of the bonus footage at a meeting:-Watch one of the two example classes. Discuss what techniques you can take away from these "real world" classes.-Have an FAQ day where staff lists questions about CCNE classes. Compile that list and watch the FAQ section. See what questions get answered and what questions still need to be addressed. -Need some inspiration? Watch the 1-minute "Why We Do CCNE" to get people thinking about how important our work really is to our clients!

The CCNE training DVD is a great resource for becoming more confident with CCNE. Take some time and view the DVD in your agency. It is worth the watch!